Laserfiche WebLink
02-18-1999 08:52PM FROM <br />10 14252518782 P.07 <br />1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />i ! <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br />I <br />HE APPLICATION':FCRt INSTALLATION Of UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALMAR YEAR IN UH CH tT HAS BEEN tsSUED. <br />PERMIT MAY BEj EXTENDO INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT 70 PHS -END REWESTING THIS lISION THIRTY DAYS <br />IR ER TO TIE EHQ of THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY PHS-EHO U R:CEIPT OF THIS LETTER. <br />Do NOT WRITE IN AMY SHADED AREAS. <br />PROJECT CONTACT &TELEPHONE C s�C y�/ K/ 4ZS 051- 65pzz ! <br />EPA SITE 10 <br />FACILITY INANE /'�gcx> l� � F� )74L/ -�2 <br />PHONE Z,, <br />ADDRESS (0 CilS % �// W <br />CROSS STJEET <br />OWNER/OPERATOR <br />&7r/ — / 40 <br />ju r3t 3777L1c/ <br />CONTRACTOR <br />PHOINE <br />CONTRACTOR ADDRESS CA LIC <br />CLASS <br />NA uAS� E CERT f IED YES "NTS <br />UORX.COMP.9 <br />FIRE OIS� RICTj 7-0^1 <br />PERMIT <br />BOARD 0 £OUA IZATICu w L"-00!50 (0 <br />111111111 <br />1 � <br />11111111111Miltll.i <br />TANK IO x j TAW St'.: gMICA S Td BE STORED PROPC'SED IN ELATION <br />I <br />s <br />39- <br />L o <br />' <br />39- <br />39-�' <br />1 <br />tiUG <br />- <br />39- <br />41 <br />39- <br />I ' <br />39 -fir <br />1(li I <br />� <br />! APPROVED APPR WITH CONDITIONS) _ <br />OISAPPROVED <br />I'I i (SEE ATT HT WITH CONDIflONS) <br />REWIEW iS NAME I <br />DATE <br />PLAA <br />11(Illii�Illlllil111 1ltl 11i 1 111 11111 1l llI <br />1111111 li 1 I1 <br />AND RULES ANU XLb <br />PPLICANT �41JS7 �ERf�RM ALL tX ill ACt:OUDANCE WiT SAN JOAGUIN COUNTY ORDINANCES, STATE LAWS, <br />aN JOACu1N COl1�1T`( P1lSlIlC HEALTH SERVICES- OUJ1E OR LICENSED AG£ilT'S SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN <br />HE PERFORI1A110E OF THEIWORK FOR WHICH THIS PERM IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A KAgNER AS TO BECOME <br />uBJECT TOjWORKFR'S OPEN us OF CALIF NIA." CONTRACTOR'S HIRING OR SUBCONTRAC7ING.SIGNATURE cEATIFIES THE FOLLOWING: <br />'I <br />—T IN THEIP N OF THE ud Kt FOR WHICH THIS PERMIT IS ISSUED, I SHALL D(PLOY PERSONS SUBJECT TO WORKER'S <br />;OMPENSATION I.Ar OF IF A. <br />I i <br />i <br />�PPLICANT'� SIG�ATURE:j <br />I � I <br />tcate the res ible party to be billCd for additional PHS-EHO staff time expended beyond the 8 hour minimsa installation <br />sent. Thd party dust acknowledge this responsibility for the additional billing by sz9%tyre and date below. <br />i92�J A <br />TITLE /�--�TET�%,4i/COATS <br />ling Address I ; <br />I � <br />Phone Nuc>idert13�JS <br />Z Z <br />I <br />naLVCe I <br />Z3 008 (Rev 12 1Y <br />j, <br />- /,zz <br />S, 1994) <br />1.1 <br />Dare �� <br />